Published 9/9/2024
AAOS members should be aware of several new coding policy updates that may impact orthopaedic practices.
E/M with modifier 25
AAOS was alerted to revised policies that would reduce reimbursement for claims submitted for certain Evaluation and Management (E/M) codes appended with modifier 25 and minor global surgical procedures for professional claims on the same date of service. Carriers will reduce reimbursement by 50 percent for the service, with the lower relative value units or the provider’s submitted charges if less. The American Medical Association (AMA) Current Procedural Terminology (CPT) guidelines state that modifier 25 is appended to indicate “significant, separately identifiable E/M services by the same physician or other qualified healthcare professional on the same day of the procedure or other service.”
The policy change also goes against Centers for Medicare & Medicaid Services (CMS) policy, which states that claims containing E/M codes with modifier 25 should not be denied or subject to prepayment review except when contractors have met certain conditions. AAOS has sent communications to the carriers, urging them to rescind this policy and continue to process the E/M service at 100 percent of the appropriate allowance. AAOS was notified by Blue Shield of California that they have halted implementation of this policy. Members experiencing issues should refer their carriers to the AMA CPT and CMS guidelines when appealing their denials.
Casting codes (Q-codes)
AAOS was also alerted to members seeing denials of casting supplies (Q-codes). The denials appeared to be caused by an erroneous edit within the claims-processing software ClaimsXten (owned by LyricAI), which is utilized by several payers, such as Aetna, Anthem, Cigna, Humana, and UnitedHealthcare. The claim edit flags Q-codes as non-reimbursable or bundled into global fracture care codes, despite CPT guidelines, which state that splints and casting supplies are separately reportable. This guidance is also restated in an article on the CMS website titled “Billing and Coding: Fracture Care,” which states, “Splints and cast Q-codes are considered HCPCS Level II codes and [are] to be used when supplies are indicated for cast and splint purposes. The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.” HCPCS Level II codes identify products, supplies, and services not included in CPT codes, such as orthotics and supplies.
AAOS requested rescission of this edit and was notified by LyricAI that an updated content package has been sent correcting this edit. Members should check with their carriers to ensure they are using the most current content package and request reprocessing of any denied claims.
Members experiencing issues related to these or other policies should email willer@aaos.org for information.